Introduction Liver resection offers curative treatment to a number of malignant conditions. It has traditionally been associated with poor post-operative outcomes. More recently a mortality rate of less than five per cent has become established but morbidity remains high. Enhanced Recovery After Surgery (ERAS) has become established practice in a number of surgical specialties and has shown improvement in post-operative outcomes. ERAS has been introduced for liver resection however practice is less well established and liver surgery has several complexities that need to be accommodated in order to optimise post-operative care. The following thesis aims to identify areas that require clarification and investigate peri-operative care components to establish optimum practice. Methods Systematic review and meta-analysis were performed to identify areas that required clarification and were lacking in sufficient evidence to guide practice. A randomised controlled trial was performed to compare established areas of practice. Prospective observational studies were performed when exploratory investigation was required. Retrospective analysis of a prospectively collected database was performed to identify risk factors for post-operative morbidity. Patients included in the above trials underwent liver resection at the Royal Infirmary of Edinburgh, UK, between December 2012 and August 2014. Results Post-operative analgesia after liver resection was identified as being an area that was controversial. Continuous wound infiltration was shown to offer improved recovery times when compared to epidural with no significant associated disadvantages. After retrospective review of 603 liver resections, extended resection was observed to be associated with high morbidity rates. It was hypothesised that post-operative nutritional requirements might be higher in these patients. This was not found to be the case but post-operative energy requirements were found to be difficult to predict after liver resection, suggesting the benefits of real-time monitoring of energy expenditure. Finally acetaminophen metabolism was suspected of being altered after major resection. An observational study suggested that despite altered metabolism, glutathione deficiency was not observed after major resection and so liver volume was not a contra-indication to acetaminophen administration. Summary Liver resection offers a complex set of conditions on which to base an enhanced recovery protocol. Current ERAS literature does not completely address these issues. This thesis has investigated several aspects of care unique to liver surgery in an attempt to optimise peri-operative care and improve post-operative outcome after liver surgery.

En la actualidad, el uso de tecnologías de informacíon y sistemas de cómputo tienen una gran influencia en la vida diaria. Dentro de los sistemas informáticos actualmente en uso, son de gran relevancia los sistemas distribuidos por la capacidad que pueden tener para escalar, proporcionar soporte para la tolerancia a fallos y mejorar el desempeño de aplicaciones y proporcionar alta disponibilidad. Los sistemas replicados son un caso especial de los sistemas distribuidos. Esta tesis está centrada en el área de las bases de datos replicadas debido al uso extendido que en el presente se hace de ellas, requiriendo características como: bajos tiempos de respuesta, alto rendimiento en los procesos, balanceo de carga entre las replicas, consistencia e integridad de datos y tolerancia a fallos. En este contexto, el desarrollo de aplicaciones utilizando bases de datos replicadas presenta dificultades que pueden verse atenuadas mediante el uso de servicios de soporte a mas bajo nivel tales como servicios de comunicacion y pertenencia. El uso de los servicios proporcionados por los sistemas de comunicación de grupos permiten ocultar los detalles de las comunicaciones y facilitan el diseño de protocolos de replicación y recuperación. En esta tesis, se presenta un estudio de las alternativas y estrategias empleadas en los protocolos de replicación y recuperación en las bases de datos replicadas. También se revisan diferentes conceptos sobre los sistemas de comunicación de grupos y sincronia virtual. Se caracterizan y clasifican diferentes tipos de protocolos de replicación con respecto a la interacción o soporte que pudieran dar a la recuperación, sin embargo el enfoque se dirige a los protocolos basados en sistemas de comunicación de grupos. Debido a que los sistemas comerciales actuales permiten a los programadores y administradores de sistemas de bases de datos renunciar en alguna medida a la consistencia con la finalidad de aumentar el rendimiento, es importante determinar el nivel de consistencia necesario. En el caso de las bases de datos replicadas la consistencia está muy relacionada con el nivel de aislamiento establecido entre las transacciones. Una de las propuestas centrales de esta tesis es un protocolo de recuperación para un protocolo de replicación basado en certificación. Los protocolos de replicación de base de datos basados en certificación proveen buenas bases para el desarrollo de sus respectivos protocolos de recuperación cuando se utiliza el nivel de aislamiento snapshot. Para tal nivel de aislamiento no se requiere que los readsets sean transferidos entre las réplicas ni revisados en la fase de cetificación y ya que estos protocolos mantienen un histórico de la lista de writesets que es utilizada para certificar las transacciones, este histórico provee la información necesaria para transferir el estado perdido por la réplica en recuperación. Se hace un estudio del rendimiento del protocolo de recuperación básico y de la versión optimizada en la que se compacta la información a transferir. Se presentan los resultados obtenidos en las pruebas de la implementación del protocolo de recuperación en el middleware de soporte. La segunda propuesta esta basada en aplicar el principio de compactación de la informacion de recuperación en un protocolo de recuperación para los protocolos de replicación basados en votación débil. El objetivo es minimizar el tiempo necesario para transfeir y aplicar la información perdida por la réplica en recuperación obteniendo con esto un protocolo de recuperación mas eficiente. Se ha verificado el buen desempeño de este algoritmo a través de una simulación. Para efectuar la simulación se ha hecho uso del entorno de simulación Omnet++. En los resultados de los experimentos puede apreciarse que este protocolo de recuperación tiene buenos resultados en múltiples escenarios. Finalmente, se presenta la verificación de la corrección de ambos algoritmos de recuperación en el Capítulo 5. / Nowadays, information technology and computing systems have a great relevance on our lives. Among current computer systems, distributed systems are one of the most important because of their scalability, fault tolerance, performance improvements and high availability. Replicated systems are a specific case of distributed system. This Ph.D. thesis is centered in the replicated database field due to their extended usage, requiring among other properties: low response times, high throughput, load balancing among replicas, data consistency, data integrity and fault tolerance. In this scope, the development of applications that use replicated databases raises some problems that can be reduced using other fault-tolerant building blocks, as group communication and membership services. Thus, the usage of the services provided by group communication systems (GCS) hides several communication details, simplifying the design of replication and recovery protocols. This Ph.D. thesis surveys the alternatives and strategies being used in the replication and recovery protocols for database replication systems. It also summarizes different concepts about group communication systems and virtual synchrony. As a result, the thesis provides a classification of database replication protocols according to their support to (and interaction with) recovery protocols, always assuming that both kinds of protocol rely on a GCS. Since current commercial DBMSs allow that programmers and database administrators sacrifice consistency with the aim of improving performance, it is important to select the appropriate level of consistency. Regarding (replicated) databases, consistency is strongly related to the isolation levels being assigned to transactions. One of the main proposals of this thesis is a recovery protocol for a replication protocol based on certification. Certification-based database replication protocols provide a good basis for the development of their recovery strategies when a snapshot isolation level is assumed. In that level readsets are not needed in the validation step. As a result, they do not need to be transmitted to other replicas. Additionally, these protocols hold a writeset list that is used in the certification/validation step. That list maintains the set of writesets needed by the recovery protocol. This thesis evaluates the performance of a recovery protocol based on the writeset list tranfer (basic protocol) and of an optimized version that compacts the information to be transferred. The second proposal applies the compaction principle to a recovery protocol designed for weak-voting replication protocols. Its aim is to minimize the time needed for transferring and applying the writesets lost by the recovering replica, obtaining in this way an efficient recovery. The performance of this recovery algorithm has been checked implementing a simulator. To this end, the Omnet++ simulating framework has been used. The simulation results confirm that this recovery protocol provides good results in multiple scenarios. Finally, the correction of both recovery protocols is also justified and presented in Chapter 5. / García Muñoz, LH. (2013). Optimizing recovery protocols for replicated database systems [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/31632 / TESIS